Summary: The deceased was subject to an involuntary patient order under the Mental Health Act 1996 (WA) at the time of her death. This mandates an inquest under the provisions of the Coroners Act 1996 (WA) to examine the supervision, treatment and care of the deceased while an involuntary patient. On the afternoon of 26 March 2015 the deceased was located in bush surrounding her home by members of Armadale Mental Health Service when she did not return as planned. She was 56 years of age.

The deceased had a long history of respiratory disease, exacerbated by her continued and heavy smoking. The Deputy State Coroner was satisfied the deceased had a long and difficult history of mental health issues and was diagnosed with schizophrenia by at least 1990.

The Deputy State Coroner noted the deceased presented as physically unwell in early March 2015 and as a result was hospitalised, but due to her lack of compliance with her antipsychotic medications had also become mentally unstable. Following treatment for her physical difficulties she was assessed by the mental health team and made an involuntary patient in an attempt to stabilise her, both for her mental health issues and as a result improve her physical outcomes.

The deceased was stabilised with her medical issues and transferred to the psychiatric ward on 5 March 2015 to stabilise her mental health issues. She suffered from low oxygen saturations due to her continued smoking and respiratory disease.

The deceased chose to live in a remote location where she was not exposed to excessive human contact. It was clear her cat was extremely important to her mental welfare. On 24 March 2015 the deceased was granted overnight leave to check on the welfare of her cat. A consultant respiratory physician advised the inquest that granting overnight leave was reasonable in all the deceased’s circumstances.

The Deputy State Coroner concluded the deceased returned home, but it was unclear on the evidence as to whether she located her cat. The Deputy State Coroner was unable to determine whether the deceased became distressed as a result of not being able to find her cat and decided to stay one extra day which made her late for her return, or she had made a decision she would not return at all. On the evidence it was likely the deceased made a decision to leave her home on the morning of 26 March 2015, but became unwell as she attempted to reach the road and died.

The Deputy State Coroner found the deceased died on 26 March 2015 at Lot 519, Buckland Road, Jarrahdale as a result of Bronchial Asthma and Emphysema and death occurred by way of natural causes. She was satisfied the deceased’s supervision, treatment and care was appropriate in all the circumstances and no recommendations were made.